Female Pattern Hair Loss, PCOS Alopecia Treatment, What Works?

Female pattern hair loss (FPHL), also called female androgenic alopecia is a diffuse, non-scarring loss of hair.  The hair loss is most apparent in the frontal, central, and parietal scalp regions.  This condition is most common in adult females and its incidence increases with age.  Unfortunately, this disease shows variable responses to treatment.

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Not surprisingly, FPHL can lead to low self-esteem, poor body image, depression, and a lower over-all quality of life.

We know that the hair follicle changes in alopecia are similar for men and women, but the presentation and response to therapy is different. 

FPHL normally occurs during the reproductive years.  The second peak occurs at menopause (50-60 years of age).  A study conducted in 2001 found a 3% incidence of FPHL among 1008 Caucasian women in their 30’s.  This prevalence increased slowly with age and was 32% in the ninth decade of life.  The combined prevalence was 19%.

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Minoxidil

The first line of treatment for FPHL is Minoxidil (Rogaine).  Many are familiar with Rogaine as it has been approved for use in men’s hair-loss since 2006.

We are not completely sure how minoxidil works but it is thought to promote the growth phase of the hair follicle, shorten the resting phase, and enlarge miniaturized follicles.

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 In 2014, 5% minoxidil was approved for FPHL.  Before this, only 2% minoxidil solution was approved for use in women.  Studies have shown that once daily application of a 5% foam is as effective as twice daily application of a 2% solution.  This is important because once daily application is more convenient for the patient. 

There are side effects associated with the use of minoxidil.  During the Rogaine clinical trials conducted by Johnson and Johnson, the following side effects were reported in at least 2% of the study participants.

  • Weight Gain
  • Headache
  • Itching
  • Nasal and upper respiratory tract infections        4

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One of the common concerns among women using hair growth products is the worry of hair growing in the wrong places.  Hypertrichosis has been reported with both strengths of minoxidil but is significantly less with the 5% foam.

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It is recommended that minoxidil be applied at least 2-4 hours prior to bedtime with hands thoroughly washed after application to limit unwanted hair growth on the face.

Although I do own stock in Johnson and Johnson, I currently am not paid for promoting their products.  I have included the link to the Rogaine site below as a convenience to my readers.  Both 2% solution and 5% unscented foam are available at:

https://www.rogaine.com/products/womens-hair-regrowth-solutions#women

Other Treatment Options

If Minoxidil is ineffective, other medications may be tried.  It is important to note that although these secondary treatments may be tried, no conclusive evidence supporting their effectiveness is available.  In fact, a Cochrane Review including 47 trials with 5290 subjects, found only minoxidil to be effective for FPHL.

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Although evidence is lacking, these systemic treatments are still utilized in some situations.  They will be briefly discussed here.

Spironolactone

Spironolactone is an aldosterone antagonist.  It works by blocking androgen receptors and has some inhibition of androgen synthesis.

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It is usually the initial second-line agent employed for FPHL because it is often used in women for other indications such as acne, hirsutism, and polycystic ovarian syndrome.  This gives providers more confidence in regards to side effects and tolerability.  Spironolactone has limited positive data available for its use in FPHL.  One open-label study treated patients with either spironolactone or cyproterone.  The average duration of treatment in this study was 16 months.  There was not difference between the groups.  Forty-four percent of the patients experienced regrowth of hair, forty-four percent showed no change, and twelve percent had continued hair loss.

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Finasteride

Finasteride is often used to treat baldness in men.  It works by inhibiting the conversion of testosterone to dihydrotestosterone.  This medication is usually well tolerated in females and because of the limited options for women who fail minoxidil, it may be another option.

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Flutamide

Flutamide has a few studies supporting its usefulness in FPHL.  In one prospective cohort study of 101 premenopausal women, flutamide was associated with an average of 15% improvement of hair thickness at six months and 28% at two years.

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Another case study found flutamide reversed hair loss in a patient who had failed treatment with a combination of spironolactone and topical minoxidil.

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Flutamide is associated with side effects such as decreased libido, GI distress and rarely liver failure.  The threat of liver failure has limited flutamide’s use in FPML.

Low-Level Laser Light Therapy (LLLT)

Photobiomodulation therapy, or low-level laser light therapy has also been used to treat FPHL.  A study published in 2014 in The American Journal of Clinical Dermatology found a clinically significant difference in terminal hair density between an FDA approved low-level laser product (Lasercomb) and a sham device.  This was a randomized, double-blind sham device controlled study of 128 male and 141 female subjects. 

The patients who used the Lasercomb also reported an improvement in hair thickness and an overall improvement of their hair loss condition as compared to the sham treated patients. 

There were no serious adverse effects reported with the use of the Lasercomb.  This device may be a good alternative for hair-loss patients who either do not respond to medications or have adverse effects or contraindications to available treatments.

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More information on the Ultima 9 Classic LaserComb can be found at:

https://hairmax.com/products/ultima-9-classic-lasercomb?variant=30328901664886&currency=USD&gclid=Cj0KCQiApt_xBRDxARIsAAMUMu_CUgG6KDzv5d4DMnuOrpiGeL5NHVb0edgODpcXETrwB8E1rGCknE8aArzhEALw_wcB

Surgery

When all other treatments fail, hair transplantation surgery is an option.  Unfortunately, this is not always effective as transplant failure is possible.  This procedure is also costly and time-consuming for the patient.  There may also be an increased amount of hair loss early on and pain and infection is also a risk.

 

PCOS Alopecia Treatment

Polycystic ovarian syndrome (PCOS) alopecia is caused by an increase in male hormones.  Treatments for this are the same as those listed above.  In addition, birth control pills may be used to help decrease androgen levels.  Oral contraceptives not only help with hair loss but also can be effective for the treatment of other PCOS symptoms such as acne and irregular menstruation.  

There is evidence that weight loss in women with PCOS can also decrease androgen levels.  Even a loss of five to ten percent of body weight can have a significant effect on PCOS symptoms.14

Female pattern hair loss is an unfortunate ailment that increases in prevalence with age.  This condition leads to poor self-esteem, a distorted body image, and may even lead to depression.  Unfortunately, the treatments available for this disorder are scarce.  The only scientifically proven method is topical minoxidil, or Rogaine.  Other treatments have been used with some success but are not well supported by the clinical literature. 

Please leave any questions or comments below.  Thanks for reading, and have a great day!

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

The 2019 Novel Coronavirus – What You Need to Know

Coronaviruses are a group of viruses that can be transmitted between animals and humans.

These viruses can cause mild ailments such as the common cold as well as more severe infections requiring hospitalization.

The latest outbreak initiated in China has already killed 427 people worldwide, as reported by NBC News on February 4th, 2020. This is alarming since this virus has only recently been identified as 2019-nCoV on January 7th, 2020.

How is this virus spread?

What can you do to protect yourself?

How Does This Virus Spread?

Since this is a new virus, we can only speculate on how it is transmitted.  It can be assumed that its spread is similar to other coronaviruses.  These viruses are normally spread by close physical contact (usually six feet or less). 

Droplet transmission is the most likely culprit. 

When an infected patient coughs or sneezes, droplets may be inhaled by others or land in their mouths or noses.  It may also be transmitted by touching a surface contaminated with these droplets and then touching the mouth, eyes, or nose, but this is not currently confirmed.

There is no vaccine against this virus at the current time.

Coronavirus Symptoms

The symptoms of the new 2019-nCoV virus are as follows

  • Fever over 100.4 degrees
  • Muscle aches
  • Breathing problems
  • Malaise
  • Cough

Some people with this virus will show no symptoms but may still spread the virus to others.  Some patients may have severe symptoms such as pneumonia, hypoxia, and even death.

The risk of death is higher in those who are immunocompromised, prone to pneumonia, elderly or frail.

Coronavirus Treatment

There is currently no treatment for this virus other than supportive measures.  Viruses are difficult to treat with medications.  A hospital stay may be necessary to keep the patient comfortable and prevent the condition from deteriorating.  In severe cases, being treated in the ICU to support breathing may be necessary. 

The FDA has approved the use of hydroxychoroquine (Plaquenil) on 3/30/2020 for the treatment of COVID-19.  This drug helps dry secretions in the lungs.  One of the main causes of death from this virus is respiratory failure.

Prevention of Coronavirus

The best way to prevent this infection is to stay away from others who have it, wash your hands often, and clean work surfaces used by others frequently.  Since it is not possible to know who has the virus, the recommendation is to stay six feet away from everyone.  It is also mandated that people in the USA stay home unless they must shop for food or are in critical positions and must go to work.  The social distancing guidelines are in effect until April 30, 2020.

If you are not familiar with the correct hand-washing technique, please refer to:

 https://www.cdc.gov/handwashing/

  • Hand washing is extremely important for optimal health.
  • If you don’t need to travel to China, don’t. 
  • Avoid touching your eyes, nose, or mouth with unwashed hands.
  • Cough or sneeze into a tissue and promptly throw the tissue in the trash.

If you are living with someone who you think may be infected with coronavirus, do the following:

  • Stay in a separate room and use a different bathroom if possible
  • Clean all surfaces the infected person may have had contact with well!
  • Wear disposable gloves, a disposable gown, and a face mask when caring for them, be sure to wash your hands thoroughly after providing care.
  • Have the infected person wear a mask if possible. If this causes breathing problems, others in the same room as the patient should wear a mask.
  • Keep all surfaces very clean, especially ones the patient comes into contact with.

What if I Get Infected?

If you believe you have contracted this virus, see your doctor.  This is especially important if you have a high fever or trouble breathing.  Do not go to highly populated areas as this may cause the disease to spread.  Stay home from work.  If you are severely ill, go straight to the emergency room. 

The hospital or doctor will test you to confirm you are infected with 2019-nCoV.

It is important to stay away from elderly patients, those who are immuno-compromised, small children and anyone who is susceptible to pneumonia if you suspect you may have this virus. 

Protecting yourself against the coronavirus is much the same as avoiding other illnesses.

Stay away from other infected individuals.

Wash your hands often.

Do not travel to destinations where the disease is prevalent.

Wear protective clothing (masks, gowns, gloves) when caring for others with the condition, and keep yourself in good physical condition.

This virus is more dangerous in those with pre-existing respiratory problems, those who are immunocompromised, and the elderly and frail.

If you have any questions, feel free to contact me.

UPDATE

 As of 03/30/2020, there have been over 143,000 deaths attributed to this virus in the USA.  This has turned out to be much worse than originally thought.  The best resource I have been able to find for updated information can be found at the link below.

https://coronavirus.jhu.edu/

Stay safe, and always remember to be happy and healthy.  Please follow the guidelines issued by the government regarding this virus.  Many lives depend on it!

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
Woman in sensory room holding fiber optics

Snoezelen Therapy for Dementia Patients

Woman in sensory room holding fiber optics

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

The world population is ageing and, because of this, the incidence of dementia has risen.  According to the World Health Organization, approximately 50 million people have dementia worldwide, and 10 million new cases are diagnosed every year.  The incidence of dementia is expected to reach 131 million people by 2050.1

  Dementia has a tremendous impact on both the patient, and the family.    Patients with dementia are unable to remember things, have a difficult time solving problems, and can become easily frustrated.  Their sleep-wake cycle may become reversed and, at times, they may even become violent to the ones they love.  Dementia occurs in older people but is not a normal part of the ageing process.

Dementia patients may reach a point where they need to be hospitalized due to behaviors which are not able to be controlled by their caregivers.  Some of these behaviors include agitation, depression, aggression, and apathy.

I have been working on a unit which cares for dementia patients for three years.  During this time, I have learned a great deal about this condition as well as common and not so common treatments.  I have written other blog posts relating to dementia but this post will concentrate on the use of Snoezelen therapy for these patients.

A Snoezelen room is a controlled multisensory environment (MSE).  Equipment in these rooms cause a variety of stimulation including tactile, auditory, olfactory and visual.  Snoezelen rooms should provide a calm and comfortable environment for the patients.  These rooms can be used for patients with autism, brain injuries, developmental disabilities as well as dementia.  MSE’s are not inexpensive to set up.  Associated costs could run from $10,000 to $30,000 and even more if complex, high-end equipment is used.

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Assessing Unmet Needs

The Unmet Needs Model suggests negative behaviors in dementia may result from the inability to communicate one’s needs to caregivers.  There are ways in which we can attempt to learn what these unmet needs are by trial and error.  In the hospital setting, we often talk about the following possibilities that may make the patient uncomfortable.

  • Pain – This one is difficult to assess. There are pain signs such as grimacing.  The patient may also be suffering from a urinary tract infection, or other ailment.
  • Constipation – Keep track of bowel movements. Constipation can be uncomfortable, and is usually easy to treat.
  • Hunger – Offer food. Attempt to learn the patient’s food preferences by speaking to those close to the patient.
  • Thirst – Offer fluids.
  • General Comfort – How the patient is sitting, temperature, clothing, etc.

If these don’t help, the patient may be suffering from boredom.  This is where the Snoezelen room can help.  Always remember, dementia patients are people like us who have a disease and it is important to view them as such.  What works for one patient, may not be effective for another.  Get to know what the patient prefers and keep track of successful interventions.  Always start with the basic needs described above.  If the patient is in pain or uncomfortable due to being constipated, a Snoezelen room experience will likely have little effect on behavior.

Benefits of Multisensory Environments in Dementia Care

Later stage dementia patients are usually unable to seek out enriching and meaningful activities on their own.  In fact, left to their own devises, they would quickly decline.  Most of the time, they are completely dependent on others for their care.  Older people are also less able to perceive sights, sounds, tastes, and smells which increases their risk of sensory deprivation.3

This can have a negative impact on health and wellbeing.4

Some believe that sensory experiences are able to trigger positive memories.  This may promote a feeling of pleasure for the patient.  Think about this in your own life.  I believe we’ve all experienced being taken back in time when we’ve smelled something that triggers a positive time in our lives, or heard a song that takes us back to a happy time.5

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The goal of the multisensory environment is to positively effect the dementia patient using sensory channels that are still intact. 

The three main avenues by which a multisensory experience can be achieved are.

  1. Daily care routines such as bathing, feeding, and administering medications 7

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  1. Sensory enhancements of the patients living environment. This may include special units in long-term care facilities which provide staff specially trained to care for dementia patients, special activities geared towards these residents and involvement of the family.9

  1. Specially designed rooms or MSEs.10

Studies have shown that MSEs can be beneficial for dementia patients.  Some of these benefits include.

  1. Decreased agitation and disruptive behavior.

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I would like to point out that some of the medications utilized to combat aggressive and disruptive behavior can cause agitation.  

  1. Increased alertness14

  1. Increased social interaction, reduced apathy, and better mood.15

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  1. Better communication with others.18

  1. Improved functional performance19

These positive attributes of MSEs leads to a more relaxed, engaged patient who gets along better with his or her peers. 

Research also shows caregivers who utilize MSEs for their dementia patients have better job satisfaction and a better relationship with their patients.

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This leads to improved patient care and reduced caregiver burnout.

Obstacles to Adding a Snoezelen Room to a Facility

Many facilities do not have the financial resources or space to implement a Snoezelen room.  As mentioned earlier in the post, these spaces can get expensive.  The institutions who have these rooms often under-utilize them.  Another problem is deciding how to design such a space.  There is much debate on exactly what to put into these rooms and research is still being conducted in this area. 

Anti-suicide regulations can also hinder certain facilities from adding a Snoezelen room.  This is especially true of psychiatric facilities where dementia patients may end up due to negative behaviors.

Perspectives of an Expert

I have the pleasure of sharing an office with an occupational therapist.  Kendra Munroe, OTR/L works with our patients daily and was the person who designed our sensory room.  Our main piece of equipment is a Vecta which was purchased from TFH Special needs Toys.  This company specializes in sensory-focused equipment and toys which promote learning and living skills.

The Vecta Full Mobile Sensory Station can turn any room into a relaxing, distracting and empowering multi-sensory room. 

According to Kendra, the sensory room “provides a safe and contained spot where the patients can explore”.  She explains that you want to have different things available to engage their senses.  Some examples include music that is tailored to the specific patients tastes, as well as things they can see or touch.  Kendra also believes it is important to include things related to nature. 

We provide weighted blankets by Salt of the Earth as well as quilts, stuffed animals, robotic pets, and a weighted baby doll to provide a realistic sensory experience.

Munroe stated that certain things are often neglected in sensory rooms, specifically regarding the geriatric population.  She mentioned things that provide proprioceptive and vestibular input in particular. “This is why we put a glider in,” Kendra explains.  We purchased a specific glider that locks in place when the patient attempts to stand.  The Thera-Glide safety glider decreases fall-risk and rocks back and forth which is soothing to the patient.

Kendra does point out that there may be dangers involved with sensory rooms.  She emphasizes that we must be trauma-informed with any of our treatment.  We must be aware that small, enclosed spaces may bother some patients.  We also need to be sure there are no objects or equipment available that the patient may throw due to confusion. 

Dementia patients should never be left alone in a sensory room.  They may become confused because the room is unfamiliar to them.  They may damage the equipment, or injure themselves.

Munroe ended by saying that we really didn’t have many guidelines available to us when setting up our sensory room.  We tried to provide a mixture of adult and pediatric sensory experiences that we believed would be most beneficial to our patient population.

Michael Brown pictured with Final Thought written

I am a big supporter of sensory rooms.  My thought is we should utilize all other treatment modalities prior to resorting to medications for dementia patients.  All drugs come with side effects and currently there are no medications indicated for the behavioral and psychological symptoms of dementia. 

Always try to meet the basic needs of the patient before moving on to other therapies.  Assess for pain, hunger, thirst, constipation and comfort. 

As a society, we have a responsibility to care for our ailing population.  This includes the mentally ill.  Unfortunately, none of us are immune from this debilitation condition.  We can all learn about it, and try to limit our risk of developing dementia.  I will continue to write about this subject as I believe it is very important.

If you have any questions regarding Snoezelen rooms or dementia in general please reach out to me.  I have access to some of the best professionals in this area. 

Please take a look at the Sunshine Store for all of your vitamin and nutritional needs.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

Probiotics Gut-Brain Axis and Psychiatry

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Is it possible to treat mental health disorders by altering bacteria in the gut?

 

What is the Gut-Brain Axis?

 

Can the drugs we use to treat psychiatric disorders make patients worse by altering the bacteria living in the gut?

 

There have been many articles and studies published recently discussing the possible connection between the microflora of the gut and the progression of neuropsychiatric disorders. The bacteria in the gut are affected by many factors, including age, diet, exercise, health, and genetics. Medications can also alter gut bacteria. This post will explore the possible effects of the gut microbiome on various psychiatric disorders. 

 

The Gut-Brain Axis

The Gut-Brain Axis is a network of nerves, hormones, and immunological factors connecting the central nervous system (CNS) to the Gastrointestinal (GI) tract. It appears that the gut flora are involved in this system. An imbalance in the function and composition of these intestinal bacteria is associated with many disease states. 1

The microbes in the gut contain genes that perform metabolic functions. The metabolites resulting from these reactions can produce local effects in the GI environment or gut wall. These microbial metabolites may also be absorbed into the systemic circulation and exert their effects on other organs, including the brain.

It is now known that there is bidirectional communication between the gut and the brain. This communication network is known as the gut-brain axis. 2

Altered microflora of the gut has been associated with depression, other mood disorders, and neurodegenerative diseases. 3

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It is known that patients with GI diseases often suffer from mental health issues. 6

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We also know that approximately one-third of patients with irritable bowel syndrome (IBS) have depression. 10

In patients with functional gastrointestinal disorders (FGIDs), 36.5% have comorbid psychiatric disorders. The most common of these are general anxiety disorder and panic. 11

Effects of Medications on Gut Bacteria

Psychiatric medications are known to disrupt the microbiome of the gut. 12

Second-generation antipsychotics, such as olanzapine, change the balance of intestinal bacteria leading to obesity.

Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) may inhibit Staphylococcus and Enterococcus growth. 13

 

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The Belgian Flemish Gut Flora Project found both benzodiazepines and antidepressants affected microbiology. 16

The classes of non-antibiotic drugs that have the highest antimicrobial activity are antidepressants, antipsychotics, and benzodiazepines. 17

 

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The drugs we use to treat these psychiatric disorders may be making the conditions worse by altering the composition of the gut flora.

It may be possible to treat psychiatric disorders with living microorganisms. The goal would be to re-establish the healthy flora in the gut resulting in an improved gut-brain axis relationship. This is a difficult subject to study because once ingested; the living organisms are subjected to many negative environmental factors, including digestive enzymes, competitive microorganisms, and pH changes. Despite this difficulty, studies have been done, resulting in positive outcomes. 

Gut-Brain Axis and Autism Spectrum Disorders

Autism spectrum disorders are developmental disorders that affect communication and behavior. This is known as a spectrum disorder because there is a wide variety of symptoms involved. Patients with autism have a difficult time communicating, may not respond to their name, and often do not find enjoyment in activities others enjoy. They may also display repetitive, stereotyped behaviors.

The exact cause of autism is not known, but children with ASD often suffer from GI symptoms that correlate with the severity of their disorder. Several studies have reported altered gut bacteria in patients with autism.    

A treatment protocol using a fecal transplant was administered to 18 children with ASD (ages 7–16 years). The protocol started with two weeks of antibiotics, followed by a bowel cleanse. The children were then given an extended fecal microbiota transplant (FMT) using a high initial dose followed by daily maintenance doses for 7-8 weeks. 

At the end of treatment, there was an 80% reduction of GI symptoms, as measured by the Gastrointestinal Symptom Rating Scale. This included a significant decrease in abdominal pain, indigestion, diarrhea, and constipation. These improvements were still evident eight weeks after treatment. The behavioral symptoms also improved significantly and also remained eight weeks post-treatment. This procedure seemed to be effective for both ASD symptoms as well as GI symptoms and continued long after treatment was completed. 21

Gut-Brain Axis and Bipolar Disorder

One study showed that patients with bipolar mania were twice as likely to have taken a recent course of antibiotics. 22

It has been suggested that treating bipolar patients with probiotics could help reduce hospitalizations. A small study found treating acutely manic patients with probiotics led to a decrease in the readmission rate. Dr. Faith Dickerson randomized 66 patients to receive a probiotic capsule or placebo for six months after hospitalization for mania. The probiotic, or placebo, were given in addition to the regular medication regimens. Of these 66 patients, 24 or 73% required rehospitalization, while only eight (24%) of the probiotic group was hospitalized. The probiotic patients who were admitted also had a shorter hospital stay than those treated with a placebo.

The probiotics used in this study were Bifidobacterium lactis (bb-12), and Lactobacillus rhamnosus (LGG). These strains are also found in breast milk. 23 

 

 

Gut-Brain Axis and Major Depressive Disorder (MDD)

It has been shown that mice raised in a sterile environment (germ-free mice) have an exaggerated response to stress. This can be reversed by inoculating these mice with feces in their early development. 24

 

This suggests that gut microbial stimulation helps to shape healthy brain development during the early stages of life. 25

 

A review published in 2017 in the Annals of General Psychiatry concluded that treatment with probiotics might improve MDD symptoms. The mechanism is likely a combination of serotonin availability as well as decreased inflammation. More comprehensive studies need to be completed to determine the utility of such a treatment in depression. At the present time, there is likely no harm in supplementing antidepressant medications with probiotics. 26

Psychobiotics

Psychobiotics are substances that alter the bacteria of the gut. These may be live bacteria (probiotics) or prebiotics. Prebiotics are compounds that change bacterial composition or activity when fermented in the digestive tract. 27

In a study of 55 healthy volunteers, subjects received either fermented milk containing Lactobacillus casei Shirota, or a placebo for three weeks. The study subjects falling into the bottom third of mood scores showed significant improvement as compared to the placebo group. There were no overall changes in mood in this study, which may suggest Lactobacillus has a ceiling effect. In other words, people who are already relatively happy may not have an increase in mood after ingesting the probiotic. 28

It is important to note that not all studies have shown benefits regarding probiotics. A recent review found little evidence of positive outcomes from these substances. 29

 

Michael Brown pictured with Final Thought written

The Gut-Brain Axis is a fascinating topic that deserves much more research. I believe we can all benefit from eating a healthy diet, exercise, and possibly probiotic supplementation.

The evidence suggests that gut bacteria are vital in helping to develop the brain at a very early stage of human development. It is also evident that many of the medications we use to treat mood disorders such as depression, anxiety, and bipolar disorder, have an effect on the microbiome of the gut.

In the future, we may be able to either successfully treat these disorders with specific bacterial agents, or supplement the healthy flora destroyed by the medications we employ to treat these maladies.

I do know that I benefitted from eating a whole food diet during my Whole30 experience. My mood improved; I slept better and was more alert and happier in general. I can’t be sure this has anything to do with the microbiome in my gut, but it is certainly possible. I hope you have learned something from this post. If you have any questions, please feel free to reach out to me.

 

In the next post, I plan to write about happiness. This is something I have been looking forward to. I want to share my secrets for staying happy and improving your mood. I think you will all enjoy it.

 

Have a great day, and stay healthy!

 

 

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Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

Ethanolism – Why You Shouldn’t Drink Alcohol

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

I enjoy a few drinks with friends.

I deserve a drink to calm down after a hard day at work.

Everybody drinks, right?

I started Sunshine Nutraceuticals in July of 2019. My goal has always been to help my readers live a happy, healthy, healing lifestyle.

I know a lot, if not most, of my readers, drink alcohol.

This post is not about judgment. It is not about right or wrong. This post is meant to give my readers the facts about alcohol. The first fact, and likely the most important is this:

Ethanol is a neurotoxin

 What this means is when you drink alcohol, you are consuming poison.

Is it worth it?

Like most of you reading this, I used to drink alcohol. When my second youngest child was born, I decided to stop. Not because I had to, but because I wanted to be more productive and was sick and tired of wasting money on alcohol. I wanted my kids to grow up in a home without alcohol.

My life today without ethanol is much better. I am in good shape, I think more clearly, my anxiety level has decreased, and I am saving money. 

I have seen hundreds of patients admitted to the hospital because of alcohol intoxication. The nurses in ICU will tell you these are some of the most challenging patients to manage. Alcohol withdrawal is no joke. It can kill you!

I have watched people die of liver failure due to ethanol. This is not a good way to go. Remember, your liver is the primary organ responsible for removing toxins from your body. Imagine living your final days with a body full of byproducts. We have dialysis to help with kidney disease, but if your liver fails, there isn’t much that can be done.

If you want to be healthy, ethanol will not help you achieve the goal.   

Sobering Statistics

It is estimated that 88,000 people die from alcohol-related causes each year.  1

This ranks third as the most preventable cause of death in the United States behind tobacco,  poor diet and physical inactivity. 2

In 2014, thirty-one percent of all driving fatalities (9,967 deaths), were attributed to alcohol impairment. 3

In 2017, 26.4 percent of people over eighteen years of age reported binge drinking and 6.7 percent reported heavy alcohol use in the past month:

Binge drinking: a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours. 4

Heavy alcohol use: Binge drinking on 5 or more days in the past month.

Alcohol Use Disorder (AUD) in the United States: According to the 2017 National Survey on Drug Use and Health (NSDUH), 14.1 million adults ages 18 years and older have AUD. 5

Alcohol Use Disorder (AUD): AUD is a chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. AUD can range from mild to severe, and recovery is possible regardless of severity. The fourth edition of the Diagnostic and Statistical Manual (DSM–IV), published by the American Psychiatric Association, described two distinct disorders—alcohol abuse and alcohol dependence—with specific criteria for each. The fifth edition, DSM–5, integrates the two DSM–IV disorders, alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder, or AUD, with mild, moderate, and severe subclassifications. 6

Over ten percent of children in the United States live with a parent with alcohol problems, according to a study published in 2012. 7

Drinking alcohol increases the risk of contracting the following types of cancers:

  • Mouth
  • Esophageal
  • Pharynx
  • Larynx
  • Liver
  • Breast 

8

Why Do People Drink Ethanol?

We will now explore the reasons people drink alcohol. Again, no judgment here. I am merely pointing out why you might drink.

Alcohol Gives Me Confidence and Helps With Socialization at Parties.

What alcohol does is dull your sense of apprehension along with other mental capabilities. Our bodies have a method to combat fear, known as the “fight or flight” response. This is the body’s way of protecting us from dangerous situations. Alcohol has a depressant effect on the brain and suppresses this response.

When our “fight or flight” system is diminished or absent, it makes us vulnerable to dangerous situations. If there is a danger, we are less likely to notice and certainly not as able to respond to it. What do we call people who are drunk? Hammered, wasted, tanked, tipsy, plastered. These words describe someone who can quickly be taken advantage of or hurt. This world is full of individuals that can’t wait to take advantage of someone in a vulnerable state. 

As far as confidence goes, I would much rather spend time with a shy person than someone who is drunk and talks nonstop. Drinking to gain confidence can easily backfire, turning the person into a fool. You are much more likely to develop strong friendships if you appear as you are rather than who you are when drunk. 

Intoxicated people also have diminished impulse control. I explain this to my students in the following way:

Suppose someone has just made you very angry. You don’t like this person and think about punching them in the face. 

Most of us would not punch them. We know there are consequences to such actions. This is an example of impulse control. We stop ourselves from doing something that will undoubtedly have negative consequences. Alcohol removes some of this control. Remember, alcohol deadens all senses, good and bad. 

Why do you suppose there are so many fights in bars? 

Alcohol does not give you any special powers, and it takes away your body’s inherent protective mechanisms.

Another thing to consider is the fact that you have to get home from that party! 

Do you have a designated driver? 

How many times have you driven when you have had too many drinks?

I don’t have to tell you what happens if you get pulled over by the police on the way home.

The least you will lose is a night of freedom and a big pile of money. You could also lose your job or even your career in some cases.

Is it really worth it?

Drinking Alcohol Relaxes Me, and I Deserve That After a Rough Day at Work!

Does alcohol relax us? 

What is it doing? 

The truth is alcohol doesn’t remove stress at all. It merely enables us to ignore our body’s innate warning system. If we are genuinely “stressed,” maybe we are trying to accomplish too much. Our body is telling us to slow down.

In fact, alcohol is very good at causing stress. 

What happens when the alcohol wears off? 

We feel anxious. Most of us want more. 

Wanting more causes stress that is only relieved when we continue to drink. The next drink does induce some relaxation, but this is only due to decreasing the withdrawal symptoms caused by alcohol leaving our body.

What will happen is the more you drink, the more stress you will invite into your life. Secondly, any problems you were attempting to forget will still be there when the alcohol wears off.

Finally, if you end up drinking too much to relax, your next day will likely be worse.

Alcohol helps Me Sleep

Not a chance. It might make you think you are sleeping better, but the sleep quality is reduced. 

Ethanol is a typical “over-the-counter” sleep aid. It increases the quality and quantity of NREM sleep during the first half of the night in non-alcoholics, but REM sleep is disrupted later. The REM stage is where we dream and is considered a restful period as our muscle tone is decreased. Do not use alcohol as a sleep aid! There are many other products that work much better with fewer side effects.

Sleep quality in alcoholics is even worse. During drinking periods as well as abstinence, altered sleep architecture leads to profound insomnia and daytime sleepiness. 9 

Alcohol and Dementia Risk

As a Clinical Pharmacy Specialist in Psychiatry, I see the consequences of substance abuse often. This is one of the subjects I am most interested in and will be writing about regularly — the unit where I currently practice has geriatric psychiatric patients. 

A large percentage of these have dementia. There are four basic types of dementia. Alzheimer’s disease, Lewy body dementia, vascular dementia and frontal-temporal lobe dementia.  

We know that chronic alcohol use can lead to dementia. 

Vascular dementia occurs as a result of a stroke. Long-term ethanol use increases blood pressure, increasing stroke risk. Alcohol consumption also increases the risk of developing type II diabetes, obesity, and atrial fibrillation. All of these increase the risk of stroke.

Alcohol abuse has also been associated with Alzheimer’s dementia:

“Research from the University of Illinois at Chicago has found that some of the genes affected by alcohol and inflammation are also implicated in processes that clear amyloid beta — the protein that forms globs of plaques in the brain and which contributes to neuronal damage and the cognitive impairment associated with Alzheimer’s disease.” 10 

Alcohol is bad for the brain. I want nothing to do with any avoidable habit that may lead to dementia.

What Alcohol is Doing to Your Body

Ethanol has an effect on every organ in the body. 

Take a look at this short youtube video on how drinking negatively affects the body:

https://www.youtube.com/watch?v=V2Aj-iJ6p38

 

Life Without Ethanol

Here are a few positive benefits of an ethanol-free life. Some of these have already been described earlier but will be repeated for emphasis.

  • Fewer calories consumed, which may lead to weight loss: It is no secret that alcoholic drinks contain empty calories. Drinking too much can derail any diet plan.
  • Better sleep quality: As mentioned above, ethanol disrupts REM sleep. This often leads to daytime sleepiness. If you combine this with a hangover, it leads to an awful day! 
  • More money to do the things you enjoy: Drinking is expensive, especially if you go to a bar. I once worked with a psychiatrist who told his patients to take half of the money they spent on their addictive substance (alcohol in this case), and spend it on something they enjoyed.
  • Improved interpersonal communication with family, friends, and colleagues: Nobody wants to be around someone who drinks too much. 

 

Michael Brown pictured with Final Thought written

Alcoholism is a significant problem in the United States. This disease leads to lost productivity, broken families, increased medical costs, and unnecessary pain and suffering. People have lost jobs, been involved in accidents, and gone through a painful divorce because of alcohol abuse.

Many drink booze to “have fun.” Is this making the situation more fun? Maybe you are having a good time because you are surrounded by people you like? Why not try to live without alcohol and see how you feel?

Ethanol does not make you sleep better. It changes your sleep patterns and robs your brain of restful REM sleep.

Think about the positives and negatives of drinking alcohol. If you think about it, drinking poison doesn’t make sense. Take it from someone who has eliminated it. You will feel better!

 It is possible to stop drinking. If you have a problem with alcohol, the most critical thing you can do is get help. Being healthy feels much better than being addicted to ethanol. Click on the following link for more information.

https://www.alcoholrehabguide.org/treatment/

This one-click may be the beginning of the healthiest thing you can do for your body! 

Don’t be shy.

You are in control of your life. 

You are responsible for your happiness, and only you can decide what goes into your body.

Eat right, exercise, get plenty of sleep, and do the things that make you happy!!

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

Migraine Abortive Treatment Guidelines and Prevention of Migraine Headache

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

A migraine is a severe headache, often accompanied by nausea, vomiting, and light sensitivity. These headaches may last from four hours to several days. The American Migraine Foundation estimates that migraines occur in 1 billion people worldwide. Migraine affects adult women about 3.25 more often than men.

 1

 

 This is likely the result of hormone fluctuations occurring in females. The fact that prepubertal children have a migraine incidence of 3-10% regardless of gender also supports the theory that hormones play a role.

 2

 

The incidence of migraines remains relatively equal in boys and girls until the age of nine. After nine, more girls experience these headaches.

 3

 

It is known that estrogen is able to cross the blood-brain-barrier freely. Obese women have a higher risk of developing migraines. This is thought to be due to increased estrogen production in the adipose tissue.

 4  5

Migraine headache ranks seventh globally for years lived with disability.

 6

Migraine Aura Triggers

In fifteen to thirty percent of migraine sufferers, an aura precedes the headache pain.

 

This is most commonly visual but may be a disturbance of speech or motor function as well. This phase generally lasts less than sixty minutes.

 

I am fortunate to have only had a few migraines during my lifetime. My headaches always begin with visual problems, and I am unable to perform simple tasks such as opening a combination lock. I also have trouble speaking and have word-finding difficulties. The symptoms I suffer mimic a stroke.

 

What are the triggers of migraine headaches?

Medication Overuse Headache

Medication overuse headache (MOH) occurs when analgesics, triptans, or ergotamine agents are overused chronically. It is essential to take medications only as prescribed by your physician. There is an increased risk of MOH with opiates, Fiorinal, and analgesic medications containing barbiturates.

 7

Medication less likely to cause MOH are hydroxyzine, metoclopramide and low-dose non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen.

 8

Medications That May Trigger a Migraine

Several drugs have the ability to trigger a migraine. These include oral contraceptives, reserpine, nitroglycerin, cocaine, nifedipine, and hydralazine.

 

 If you suffer from migraines and are taking any of these, ask your physician for a substitute. 

 

If you are using cocaine, either stop on your own or get treatment. Cocaine is very addictive and extremely dangerous.

Diet

Many foods are known to precipitate migraine headaches. Some of these include chocolate (I know, this is sad), processed meats, aged cheeses, onions, oranges, tomatoes, and some dairy products. Red wine and champagne consumption can also lead to migraines.

 

Caffeine is a double-edged sword. It can help with migraine treatment, but caffeine withdrawal can cause headaches in some individuals. For this reason, it is recommended that frequent migraine sufferers stop ingesting caffeine for a two to three month period to determine if headache frequency declines.

 9

Individuals who consume large amounts of caffeine should slowly taper off the drug to decrease the chance of precipitating a withdrawal headache.

 

It is also important to be aware of additives and food preservatives. Substances such as aspartame and MSG can trigger a headache. Whole foods are always the safest option.

 

Environment

Cigarette smoke, perfume, weather changes, loud noises, and bright or flickering lights can cause a migraine. A change in altitude and extreme heat or cold are also culprits. 


Getting too little or too much sleep can be a trigger. If possible, sleep at the same time each night for the same amount of time. Try to eat at regular intervals. Skipping meals has been shown to trigger migraines in some individuals.

Other Migraine Triggers

People with psychiatric disorders are more prone to migraines. Stress and menses also increase migraine risk.

Treatment of Migraine Headaches

It is a pretty safe bet that either you or someone you know suffers from migraine headaches. You are most likely reading this because you want to know how to make them stop! 


I am going to go over abortive treatment as well as prophylactic (preventative) treatment of migraines. My goal is to present the medications with the most evidence to support their use. 


Please remember that different people respond to various therapies. What works for others may not work for you. I am going to present a list of the treatments that are most likely to be effective.

Biofeedback for Migraines

During my research on migraines, I came across an article that discussed the use of biofeedback as prophylaxis for pediatric migraine headaches. Even though I am a pharmacist, I will always recommend non-drug treatments for patients if they are safe and effective. 

 

There is not a single medication that does not possess side effects.

 

Biofeedback is where patients learn to control automatic bodily functions through the use of feedback such as temperature or muscle tension. When properly trained, the patient can control the temperature of their hands, for example, without the use of equipment.

 

When we are under stress, the blood vessels in our hands become smaller. With less blood flowing, the temperature of our hands decreases. By learning to relax using biofeedback, it is possible to lower the stress level, which increases the size of the blood vessels leading to warmer hands.

 

But does this work for migraines?

 

Nesoriuc and Martin published a meta-analysis on the effectiveness of biofeedback for migraine in 2007. They reviewed 55 studies, which included 2229 migraine patients. 

 

The conclusion was that biofeedback significantly and substantially decreases the pain and psychological symptoms after only eleven sessions. This led to the recommendation that biofeedback can be used as an evidence-based behavioral treatment option for migraine headache prevention.

10

A meta-analysis looking at biofeedback as prophylaxis for pediatric migraine was conducted in 2016. The researchers concluded that biofeedback is most likely effective, especially when combined with relaxation therapy. Since the number of studies was small, and they had methodologic issues during the meta-analysis, their recommendation is to continue research on this topic.

 11

Migraine Abortive Treatments According to the Guidelines

When you get a migraine, it can be disabling. Light, noise, and even movement can make the pain worse. 


The first thing most people reach for is Excedrin migraine or ibuprofen. Excedrin migraine is acetaminophen (Tylenol) and caffeine. If this works for you great, but remember, if you get migraines often, you should avoid caffeine. 


The over-the-counter medications with the best data to support use in the treatment of a migraine headache are aspirin, ibuprofen, and naproxen sodium. If these are ineffective, see your doctor.


What are the first-line treatments for migraines?

Triptan Drugs for Migraines

Triptans are first-line for migraine pain relief. There are several drugs in this class. Imitrex (sumatriptan) is the most common. Imitrex comes in a variety of dosage forms, including nasal spray, tablets, transdermal patches, and subcutaneous injection. The injection is the fastest acting and also the most effective. Remember, nausea often occurs with a migraine, so taking anything by mouth can lead to vomiting. 

 

The triptans work by making the blood vessels in the head smaller. These drugs should NOT be used in hemiplegic or basilar migraines.

 

There seems to be a difference in the effectiveness of the triptans in individual patients. My advice is to see what your insurance company covers and start with that. If it doesn’t help, try another agent. The most significant difference in the individual triptans is the dosage forms available and the onset and duration of action.

 

Triptans available are listed below:

 

  • Sumatriptan (Imitrex) – Injectable is ultra-fast acting and the most effective. Also available in tablets, nasal spray.
  • Rizatriptan (Maxalt) – Available in disintegrating tablets and regular tablets.
  • Zolmitriptan (Zomig) – Tablets, disintegrating tablets, and nasal spray
  • Naratriptan (Amerge)- Slow acting/ long-lasting
  • Almotriptan (Axert) – Tablets only.
  • Eletriptan (Relpax) – Tablets only
  • Frovatriptan (Frova): Longest acting triptan

Dihydroergotamine (Nasal Spray) for Migraines

Dihydroergotamine is available as a nasal spray (Migranol), as well as an injection that can be given intravenously, subcutaneously, or intramuscularly.

It works by constricting blood vessels. Like triptans, this medication should not be used in hemiplegic or basilar migraine.

Only the nasal spray received a level A recommendation from the American Headache Society (AHS).


The drugs in this class were the treatment of choice before the triptans were available. Ergot alkaloids such as dihydroergotamine should not be given along with protease inhibitors, macrolide antibiotics, or antifungal agents.

Ask your doctor or pharmacist if you have any questions about this.


Ergot alkaloids have many side effects, but the most common is nausea and vomiting. The nasal spray is the preferred route of administration due to less nausea.

Other Level A Recommendations for Aborting Migraines

Acetaminophen (Tylenol): Good choice for pain, especially in older individuals or those with kidney problems.

 

NSAIDs: Aspirin, ibuprofen, and naproxen sodium have the most evidence.

 

Opiates: May be useful but not recommended for chronic use. Side effects and addiction potential may outweigh benefits.

 

Sumatriptan/naproxen (Treximet)-A combination product promoted by the drug company. 

 

Acetaminophen/Aspirin/Caffeine (Extra strength Excedrin)-Works very well for some but careful with caffeine.

Migraine Prevention Treatments According to Guidelines

If you experience migraine headaches often or are having to miss work on a regular basis, you may wish to take something to help prevent the headaches.

Which therapies are recommended?

Aniticonvulsants

Depakote for Migraine Prevention

Divalproex (Depakote) has substantial evidence to support its use in the prevention of migraine headaches. A Cochrane review published in 2013 found patients taking Depakote were twice as likely to decrease migraine frequency by 50% or more than those taking placebo.

 12

 

Depakote does have adverse effects and risks associated with its use. It can cause congenital disabilities and should be used with caution in women of childbearing age. It also may cause weight gain, nausea, hair loss, and dizziness. Depakote has also been associated with liver failure, but this is uncommon. 

Topamax for Migraines

Topamax also has a Cochrane review that supports its use in migraine prevention.

 

This review looked at seventeen trials and found topiramate to be two times more likely to decrease the frequency of migraines by 50% or more when compared to placebo.

 13

 

Topamax can decrease appetite and commonly causes a burning or prickling sensation in the feet, arms, legs, and hands. It may also cause nausea, difficulty with memory and concentration, kidney stones, and word-finding problems.

 

 

Other Level A Recommendations to Prevent Migraines

For women who suffer from menstrually associated migraines (MAM), frovatriptan (Frova) should be offered for short-term relief.

 14

 

Treatment of Nausea Occurring with Migraine

More than two-thirds of patients who experience migraine headaches vomit during their attack.

 15  16

Many drugs used for nausea and vomiting can also be used to treat migraines. Below is a list of the most popular agents that fit this category.

Promethazine for Migraines

Promethazine is a drug used primarily for nausea and vomiting. It can also be effective in the treatment of migraine and received a level B recommendation (probably effective) from the AHS.

 17

 

This medication is available in multiple dosage forms such as tablets, injection, syrup, and suppositories. This makes promethazine useful during a migraine accompanied by nausea and vomiting. 

 

Promethazine has the potential to be abused due to its sedative effects and its ability to cause delirium. It is also known to increase euphoria when combined with opiates.

The recreational drug “purple drank” is a mixture of promethazine with codeine, hard candy, and carbonated soft drinks.

 

This mixture is popular among the hip-hop culture.

 

Promethazine should not be used in patients with asthma.

It can cause many side effects such as nausea and vomiting, dry mouth, problems breathing, dizziness, and sedation.

Chlorpromazine for Migraines

Chlorpromazine (Thorazine) is also a level B recommendation, according to the AHS. This medication is a phenothiazine that blocks dopamine receptors. This is how it works as an antipsychotic agent.

 

Chlorpromazine also possesses anti-nausea effects.

A study conducted in 2002 found chlorpromazine to be significantly better than a placebo in treating migraine headaches in the emergency room.

 18

 

 Chlorpromazine does cause a high level of sedation and postural hypotension. It is a highly anticholinergic drug leading to dry mouth, blurred vision, constipation, and confusion. It is available as a tablet and injectable form.

 

Droperidol for Migraines

Droperidol is also probably effective in the treatment of migraines, according to the AHS.

 

I have spent countless hours working in the hospital setting, and I definitely received complaints when droperidol was on back-order.

 

It is undoubtedly one of the favorite agents used for migraine at my institution. 

 

Droperidol can have some pretty severe cardiac side effects. It may also cause anxiety, restlessness, and a dysphoric mood. 

 

This drug is normally used as a pre-anesthetic agent for sedation before surgery. Droperidol has a very short duration of action. 

 

It is only available in an injectable form.

Metoclopramide for Migraines

Metoclopramide (Reglan) is also classified as probably effective by the AHS. It is available as a tablet and as an injectable form. Reglan should not be used in patients with epilepsy. Headaches may be caused by Reglan in some individuals. Drowsiness, nausea, vomiting, and movement disorders may also occur with its use.

Alternative Migraine Treatments

There are migraine treatments available that utilize dietary supplements and other medications such as Botox.  I have included some of the most popular and effective therapies below.

Botox Shots for Migraines

Botulinum toxin type A (BTX-A) was approved for the treatment of adult chronic migraine headaches in 2010.

 

Most of the data which led to this approval was obtained from two randomized, placebo-controlled, double-blind studies also published in 2010.

 19   20

BTX-A is administered intramuscularly at a dose of 155 units once every twelve weeks. Each dose should be equally divided and administered to thirty-one specific muscle regions of the head and neck, as shown below.

 

 

 

 

 

The images above were taken from the Botox package insert by Allergan, 2019

According to the American Academy of Neurology (AAN), BTX-A is safe and effective for chronic migraines and is probably effective for improving health-related quality of life (QOL) for these patients. They recommend offering BTX-A to chronic migraine sufferers to increase the number of headache-free days and improve QOL. 

 

Chronic migraine is defined as fifteen or more headaches per month for at least three months. These headaches must last four hours or more.

The AAN recommends against the use of BTX-A for episodic migraine and considers it ineffective for this population.

 21

 

 An updated Cochrane systematic review was published in the British Medical Journal in 2019. This review included twenty-eight trials, which included 4190 subjects. 

 

I prefer to cite Cochrane reviews whenever possible as they are reliable, and their evidence has the most impact on the scientific community.

 

They also update their studies when new information becomes available, as is evidenced in this subject.

 

Of the twenty-eight trials identified, twenty-three compared BTX-A with placebo injections. Three of the trials compared BTX-A with other migraine prophylactic drugs.

 

The studies comparing BTX-A to placebo included 23 trials with 3912 subjects. The analysis showed a reduction of 3.1 days of migraine occurrence per month in the BTX-A group.

 

In an episodic migraine subgroup of 418 subjects, no difference was found between the two groups.

 

It should be noted that BTX-A is very expensive compared to other treatment options.

 

It should be reserved for those with chronic migraine headaches who do not respond or cannot tolerate other therapies.

Butterbur for Migraine Headaches

Petasites hybidus, or butterbur, is a shrub that grows in wet, marshy soil. The large leaves have traditionally been used to wrap butter during warm weather to prevent melting.

This plant has been used to treat fever, cough, asthma, and wounds of the skin.

It is important to note that unprocessed butterbur contains pyrrolizidine alkaloids (uPA). These may be harmful to the liver if ingested over a prolonged period.

Butterbur, which has been processed to remove uPA is safe to consume.

 22

 

There have been studies comparing butterbur to placebo.

In one study conducted in 2000, sixty men and women who suffered from a least three migraines per month were given either 50 mg butterbur extract or placebo twice daily for three months. Seventy-five percent of the butterbur group reported improvement in the number of attacks and total number of days with migraine pain, compared to only twenty-five percent of the placebo group.

 23

Another study administered either 50 mg butterbur extract twice daily, 75 mg butterbur extract twice daily, or placebo twice daily to 202 people with migraines for three months. Patients in all three groups saw improvement in their headaches, but the 75mg butterbur group saw significant improvement as compared to the placebo group.

 24

 

Magnesium and Riboflavin for Migraines

A meta-analysis published in 2014 compared IV magnesium with placebo in emergency room patients presenting with migraines.

 

Subjects received either IV magnesium, a dopamine antagonist, or a placebo.

More patients experienced pain relief in the magnesium group than in the placebo group, but it was not statistically significant. 

 

This study also discovered magnesium works better in patients who have migraine with aura. There was no difference in effectiveness between magnesium and placebo in patients with migraine without aura.

 

It was also discovered that the magnesium-metoclopramide combination led to more pain relief than the placebo-metoclopramide combination.

 25

 

Riboflavin has been found to be effective at reducing the number of migraines when taken at a dosage of 400 mg per day.

 

In a study of fifty-five patients, 400 mg of riboflavin daily was found to be superior to placebo at reducing both the number of headache days and the frequency of migraines.

 26

 The most common side effects of riboflavin are diarrhea and increased urination. 

 

Both magnesium and riboflavin can be found in many foods:

Feverfew and Ginger for Migraines

Feverfew (Tanacetum parthenium) is a plant with flowers resembling daisies that grows wild throughout the world. This plant has previously been used for its anti-inflammatory properties and pain related to menses in women. 

Tanacetum has been used to prevent migraine headaches. The flowers contain a compound known as parthenolide, which is thought to decrease the incidence of migraines utilizing multiple mechanisms of action.

Inhibition of cyclooxygenase-2, tumor nucrosis factor-alpha, interlukin-1, 

 27

and serotonin

 28

are all thought to be involved.

A systematic review of the literature regarding feverfew and migraine was published in the Journal of Dietary Supplements in 2009.

 29

Some interesting information was gleaned from this study. It is possible that other compounds contained in the feverfew leaves assist in parthenolide’s mechanism of action. 

 

One of the studies found no benefit of an alcohol extract of parthenolide, while two other studies using dried leaves found a statistically significant decrease in migraine severity and frequency.

 

These studies found feverfew to be safe with no difference in adverse effects as compared to placebo.

 

It is important to note that feverfew is a supplement which is thought to prevent migraine, not treat the actual headache. For this reason, patients will be taking the supplement over an extended period.

 

More studies are needed to assess the long-term safety and recommended dosage of this supplement.

 

Can ginger fight a migraine headache?

 

Ginger is a common spice used in cooking. It is also used to cleanse the palate in between the consumption of various types of sushi.  Ginger is native to southeastern Asia.

 

This plant has been used for many medical purposes, including treatment of motion sickness, generalized pain, vertigo, arthritis pain, and dyspepsia.

 

One study conducted in 2005 found Gelstat (an OTC drug containing ginger extract) completely alleviated migraine pain in forty-eight percent of patients within two hours.

 

Thirty-four percent achieved partial relief during the same period.

 30

 

In a study published in May of 2013, Maghbooli et al. compared ginger to sumatriptan in the treatment of migraine headaches.

 

One-hundred patients were selected to either receive ginger or sumatriptan if a headache occurred. 

 

Twenty-two percent of the sumatriptan group and twenty percent of the ginger group had a severe headache during the study and were treated. 

 

Seventy percent of the sumatriptan group and sixty-four percent of the ginger group had their headache pain decrease by at least ninety percent two hours following drug administration.

 

There was not a significant difference between the two treatments regarding migraine pain relief.

 

The only side effect reported by the ginger group was dyspepsia. Alternatively, the sumatriptan group reported dizziness, dyspepsia, vertigo, and sedation.

 

Although this study had a limited number of subjects, it shows promise in ginger’s ability to fight migraine headache pain.

 31

A dosage recommendation of 500 mg ginger taken at headache onset and repeated every four hours up to 2 grams daily for three to four days has been recommended by Mustafa and Srivastava.

 32

 

Try Turmeric with Ginger for your Migraine

Michael Brown pictured with Final Thought written

Migraine headaches are a common health problem today. They lead to decreased productivity, increased health care costs, and a lower quality of life. 

 

There are many treatments for this disorder. Choosing the right therapy depends on several factors. Patients who have nausea and vomiting occurring with their headaches may benefit from an agent that is available as a non-oral dosage form. 

 

Elderly patients or those with kidney disease should be careful with NSAIDs. These drugs can damage the kidneys, especially if taken over a long period.

 

Those who suffer from multiple monthly migraine attacks may want to consider preventive drug treatment. Again, there are many options to accomplish this, and they are patient-specific.

 

I suggest keeping a headache journal. Write down what you eat each day, your activity level, exposure to smoke or strong odors, and hours of sleep as well as the level of stress. Try to find a pattern that leads to your headaches. It may be easier to avoid foods or other factors that cause your headaches than to use medications. 

 

Consider biofeedback. It does take an initial time commitment but may pay off in the future if you can learn to master it.

 

Other alternative therapies, such as vitamins and nutraceuticals, may also decrease headache frequency. It is possible to get some of these just by eating certain foods.

 

More studies should be done in the future regarding these agents in the treatment and prevention of migraine.

I have covered the medications with the most evidence in this post. There are many more second and third-line agents available as well.

 

At times it may be necessary to combine medications to get the desired effect.

 

If you have any questions regarding migraine headaches or any other topic, please feel free to send me a message. I am always happy to help whenever possible.

 

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

Fibromyalgia Causes And Treatment With Guaifenesin, Amitriptyline, Kratom, Flexeril, And Others.

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Fibromyalgia (FM) is a disorder affecting approximately 2% of the world’s population. FM is characterized by musculoskeletal pain occurring throughout the body. Patients with this condition may also suffer from:

 

  • Fatigue
  • Mood problems
  • Memory issues
  • Sleep disturbances
  • Headaches
  • Anxiety
  • Depression

  

FM is a chronic disorder with subjective symptoms making diagnosis difficult. At present, FM cannot be diagnosed based on objective data.

 

Fibromyalgia has previously been thought of as a diagnosis to use when symptoms did not fit any other condition. Some physicians are still unsure whether this is an actual disorder. Patients may become depressed or frustrated due to a lack of compassion from various caregivers. 

Previously, many physicians believed patients were using fibromyalgia as an excuse to obtain pain medication. We are now finding that changing one’s lifestyle may be more effective than drugs. 

Suspected Causes of Fibromyalgia

The exact cause of fibromyalgia remains a mystery. It is most likely due to several factors. We believe some of these include:

  • Genetics: Fibromyalgia is more prevalent in people who have genetic relatives with the disorder. This leads us to think it may be due, at least partially, to a genetic mutation.
  • Trauma: This may be emotional or physical. We know that in some cases, fibromyalgia occurs after the person sustains an injury or experiences emotional stress. Victims of child abuse have a higher incidence as do those with posttraumatic stress disorder (PTSD). The brain may react differently to stress and pain in these individuals which may explain this link.
  • Mood disorders: Individuals with any mood disorder, including anxiety and depression, are more likely to suffer from fibromyalgia. 
  • Gender: Women are three times more likely to be diagnosed with fibromyalgia compared to men. 1This may be due to a difference in how women react to pain or society’s expectations of how women should respond to pain.
  • Sedentary lifestyle: People who don’t exercise are much more likely to suffer from fibromyalgia. Exercise is one of the main treatments.

There is some thought that FM may be the result of the body overreacting to pain signals. This could be due to an imbalance of neurotransmitters in the brain.

 Even weak signals may be perceived as pain if this is true.

The main obstacle in determining fibromyalgia’s cause is the fact that most people with this disorder also suffer from other conditions. 

Many have rheumatoid or osteoarthritis, migraine headaches, various mood disorders, and other maladies that cause pain. It is challenging to separate FM from these coexisting conditions.

A large number of the studies conducted on this subject have a small sample size, or patients are lost to follow up. More well-designed studies are needed to determine the causes of this debilitating condition.

Cymbalta for Fibromyalgia

A meta-analysis was performed using data from the year 2000 until March of 2019.  The purpose of this analysis was to determine efficacy and proper dosage of Cymbalta (duloxetine) in the treatment of fibromyalgia. This included seven studies with 2642 fibromyalgia patients. The results showed duloxetine was more efficacious than a placebo for pain control in these patients. 

The standard mean difference between duloxetine and placebo was -0.26 or 26% better pain relief. 

There were more adverse effects suffered by the duloxetine group, and withdrawal effects were more significant in those receiving 120 mg/day. The study concluded duloxetine was a great choice for relief of pain in fibromyalgia patients

 2

A study published in June of 2019 compared duloxetine (Cymbalta) with pregabalin (Lyrica) in the treatment of fibromyalgia. 

All subjects were women with FM between 18-65 years of age. They were each assigned either duloxetine 30-60mg daily or pregabalin 75-150 mg daily for four weeks. 

The Widespread Pain Index (WPI) was used to measure pain severity. This scale quantifies body pain by asking patients if they have pain or tenderness in 19 body regions. The higher the score, the more widespread the pain. Duloxetine was significantly better in improving the WPI score with a mean difference of (-2.32) when compared with pregabalin.

The prevalence of nausea and the dropout rate was significantly higher in the Duloxetine group as compared to the pregabalin group.

 3

A Cochrane database review was published in 2018 titled “Serotonin and noradrenalin reuptake inhibitors (SNRIs) for fibromyalgia.” This was a comprehensive study focusing on the efficacy of SNRI’s on numerous FM symptoms.

This study concluded that only a minority of patients might benefit from treatment with duloxetine or milnacipran. Most patients will not gain relief from FM symptoms, or they will experience adverse effects leading to drug discontinuation. 

There is no evidence to support the use of other SNRIs such as venlafaxine or desvenlafaxine in the treatment of FM.

 4

Lyrica and Neurontin for Fibromyalgia

There was a Cochrane review published on the effects of anticonvulsants on FM. Since the lead author received financial support from commercial sponsors, this review has been withdrawn from publication.  

 

This study was, however, listed as a reference in the European League Against Rheumatism (EULAR) revised recommendations for the management of fibromyalgia. 

 

Pregabalin is listed as a pharmacotherapy for severe pain and severe sleep problems. Neurontin (gabapentin) is not recommended in the treatment of FM, according to EULAR.

 

Amitriptyline for Fibromyalgia

There is evidence that amitriptyline can help with sleep, fatigue and pain in FM at low doses. Five reviews involving 919 subjects found those receiving amitriptyline were 60% more likely to acheive a 30% reduction in pain. A moderate improvement in sleep and a small effect on fatigue were also shown.

 5

Guaifenesin and fibromyalgia

Guaifenesin is an expectorant used primarily to loosen mucous in the airways. This helps the patient cough up the mucous and remove it from the body leading to more effective breathing. Guaifenesin is sold under the popular brand name Robitussin. It is also available under the brand name Mucinex as a 12-hour tablet formulation.

 

There is a protocol available on line that promotes the use of guaifenesin in the treatment of fibromyalgia. I do not see any harm in trying this method if you suffer from FM. Guaifenesin has few side effects. It is important to note that this protocol states that salicylates of any kind must be avoided for guaifenesin to be effective. This includes aspirin and all topical salicylate formulations. The protocol can be found at the link listed below:

 

http://www.fibromyalgiatreatment.com/the-guaifenesin-protocol.html

 

A study conducted in May of 2009 used a telephone survey of 632 women to gain insight into the subjective pain relief obtained by several agents in the treatment of FM. 

 

Of the women surveyed, 434 claimed to have FM while 198 denied having the condition. The women had an age range of 18-80 years. 

 

The results of this study showed that half of the FM group were taking antidepressant medication. Tri-cyclic antidepressants (TCA’s) had strong effectiveness while serotonin reuptake inhibitors (SSRIs) had only moderate effectiveness in treating FM. Few were taking SNRI’s at this time. 

 

Almost 30% of the FM sample were taking non-steroidal anti-inflammatory drugs (NSAIDS). 

 

I included this study because even though it was conducted in 2009, it showed that the most effective medications to treat FM according to the subjective reports of the patients were opiate narcotics and guaifenesin. The narcotics aren’t surprising, but guaifenesin is.

 6

Kratom for Fibromyalgia

Kratom is a substance obtained from a tropical evergreen tree found in Southeast Asia. This substance has been used for centuries to improve stamina and increase the energy of workers in its native region.

Kratom is available as a supplement in the US. People utilize it to treat diarrhea, pain, and to decrease the symptoms of opiate withdrawal.

An anonymous national survey was conducted in 2016 in an attempt to discover the usage patterns of Kratom in the US. This survey included 8049 Kratom users.

It is known that Kratom is used as an alternative to opiates. Fibromyalgia had the lowest proportion of “significant improvement” responses in this survey. This is expected as opioids are not recommended as a treatment for FM

 7

Flexeril for Fibromyalgia

Cyclobenzaprine (Flexeril) is a muscle relaxant used for various musculoskeletal disorders.  

A systemic review of 312 patients taking cyclobenzaprine for FM found 85% suffered side effects and only 71% of the subjects were able to complete the studies.  

This review concluded sleep was slightly improved, but pain was not.  

Cyclobenzaprine can be used for severe sleep problems in FM

 8

Trazodone is an antidepressant used mostly for insomnia at the current time.  This medication was not mentioned in the EULAR revised recommendations for the management of fibromyalgia.  

If other sleep agents recommended fail, I would not be opposed to trialing trazodone. This drug is effective for sleep at low doses.  Getting the proper amount of sleep is very important.

Celexa and Fibromyalgia

Citalopram belongs to a class of drugs known as selective serotonin reuptake inhibitors (SSRIs). Seven systematic reviews were conducted looking at this drug class for the treatment of fibromyalgia. These medications may have a small effect on pain and fatigue but do not help with sleep. Since SNRI’s discussed above are more useful for FM, SSRIs are not recommended.

The EULAR revised recommendations for the management of fibromyalgia were published in 2017

 9

Michael Brown pictured with Final Thought written

The EULAR recommendations for the treatment of fibromyalgia maintain that prompt diagnosis and patient education are critical. The patient should be assessed for pain, level of function, and management should be geared towards improving the quality of life.

Non-pharmacological treatments should be initiated first. These include physical therapy with an emphasis on individualized exercise. Other therapies, such as acupuncture and hydrotherapy, may also be tried at this stage.

Psychological therapies should mainly consist of cognitive-behavioral therapy. If depression and anxiety are severe, psycho-pharmacological treatment can be utilized.

Recommendations for pharmacotherapy, according to EULAR, are as follows:

Drugs that should not be used:

  • Strong opioids
  • Sodium oxybate
  • Corticosteroids
  • Growth hormone

Drugs recommended for severe pain:

  • Duloxetine
  • Pregabalin
  • Tramadol

Drugs recommended for severe sleep problems:

  • Low dose amitriptyline
  • Cyclobenzaprine
  • Pregabalin

I have attempted to review the most up to date medication treatments for fibromyalgia in this post. I have included the recommendations from EULAR as well as information on Kratom, guaifenesin, and trazodone.

I do not recommend the use of Kratom at this time. I believe guaifenesin may have a benefit, and it has very few side effects. Trazodone is a good drug for insomnia at low doses, so it may be tried if other treatments fail.

After researching this subject, it seems that exercise, hypnosis, guided imagery, and other non-pharmacological treatments are the preferred treatment of fibromyalgia.

More research will surely be done on this subject, and hopefully we will obtain better treatments in the future.   

Thank you for reading my blog, and please contact me with questions.

Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

Several Vitamin D3 5000 IU Benefits And Why You Should Take This Supplement

Do you need to take a vitamin D supplement?

Many of us are deficient in vitamin D. The only way to be sure is to have a blood test performed. The test used is the 25-hydroxy vitamin D test. Our hospital lab lists the normal blood level to be 30.0-100.0 ng/ml. The Vitamin D council lists the ideal level between 40-80 ng/ml. I recommend supplementation in patients who have a level less than 30 ng/ml.

 

What’s the big deal? I live where there isn’t much sun! Why do I need Vitamin D?

It turns out that vitamin D performs many important functions in our body. As more research is completed, we are finding this vitamin helps with physical and mental health.

Vitamin D is one of the four fat-soluble vitamins (A,D,E and K). This vitamin is not found in many foods but is added to milk, tofu, and orange juice. Shitake mushrooms are also a good source of vitamin D.

Our bodies synthesize vitamin D when the skin is exposed to ultraviolet light from the sun. If we aren’t getting enough sunlight and eating enough foods rich in vitamin D, we are likely deficient in this vitamin.

 The other way to get this vitamin is to take a supplement. All supplements are not created equal. The Sunshine Nutraceutical Vitamin D supplement is made in the USA in an FDA inspected facility. Our supplement contains 5,000 IU of vitamin D3 in a soft gel capsule.

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Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

Being Deficient In Vitamin D Comes With A Cost. Here Are Several Problems You May Face:

Osteoporosis

Osteoporosis occurs when the body loses too much bone tissue or is unable to replace bone loss efficiently. This causes the bones to become weak and are more easily broken. People with this condition may break a bone simply by bumping into something or sneezing. 

The first sign that you have osteoporosis is usually when you break a bone. People with reduced bone density do not feel any different. The chances of a person with osteoporosis breaking a bone is 50% for women and 25% for men during their lifetime

 1

You have a higher risk of breaking a bone if you:

  • Are a smoker.
  • Have a low body weight.
  • Are female.
  • Have broken a bone previously.
  • Drink three or more alcoholic beverages daily.
  • Have gone through menopause.
  • Are over fifty years old.
  • Have low calcium and vitamin D intake 2

    The most important mineral in your bones is calcium. Vitamin D helps the bones absorb calcium. If you don’t get enough vitamin D, calcium cannot be absorbed for use by the bones. More calcium in the bones increases density which decreases the chance of a bone fracture

     3

    The incidence of broken bones increases during the winter months. Some researchers believe this is due to lower levels of vitamin D

     4

    A study published on August 1st, 2019 examined the effect of vitamin D levels on fractures in 287 elderly women with at least one previous bone fracture. This study concluded that vitamin D deficiency was associated with an increase in fracture severity as well as bone loss.

     5

General Anxiety Disorder

People with Generalized Anxiety Disorder (GAD) spend a great deal of time worrying excessively about many different things.

 

They may be convinced the world is coming to an end or always worry about money, health issues, family members, or their jobs.

 

This disorder can be debilitating if it becomes severe. People with this disorder may be afraid to leave their houses.

 

A study published in 2019 looked at the effects of vitamin D on GAD. Thirty patients with GAD and vitamin D deficiency were split into two groups of 15 patients each. One group received standard of care (SOC) only, while the treatment group received SOC plus 50,000 IU vitamin D weekly for three months.

 

The Generalized Anxiety Disorder 7-Item (GAD-7) scale was used in both groups to measure changes in anxiety levels. The vitamin D group had significant increases in serotonin levels, and their GAD-7 scores also improved. The group receiving SOC only showed no changes in GAD-7 scores or serotonin levels. 

 6

Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by a persistent pattern of impulsivity, inattention, and or hyperactivity that interferes with occupational, social, or academic functioning. This disorder may begin in infancy and may continue throughout adulthood.

 

The effect of vitamin D on ADHD was studied using fifty ADHD patients and fifty non-ADHD controls. The Conners’ Parent Rating Scale (CPRS) was used to assess ADHD symptoms, and serum 25-hydroxyvitamin D levels were measured using an ELISA kit. 

 

Vitamin D levels were assessed using the following scale:

 

Serum 25OHD less than 10 (severe deficiency)

                                10-29 (mild deficiency)

                                 >30 (sufficient vitamin D level)

 

Patients with ADHD had significantly lower serum levels of vitamin D (16.57 +/- 9.09 ng/ml) compared to the control group (22.01 +/- 12.67 ng/ml).

 

A severe vitamin D deficiency was 3.36 times more likely to be found in the ADHD group. 

 

This study supports the monitoring of vitamin D levels in patients with ADHD.

 7

Tuberculosis

Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. This disease mainly affects the lungs but may also affect the kidneys, brain, or spine. It is spread by tiny droplets in the air produced when an infected patient coughs or sneezes. This disease can be life-threatening. 

 

A nested case-control study was conducted looking at the effect of vitamin D on decreasing the progression of tuberculosis (TB).

 

Vitamin D has shown to have some impact on immunity. Vitamin D deficiency may also increase the risk of TB due to its effect on diabetes. Diabetes is a known risk factor for TB, and vitamin D is known to decrease diabetes risk.

 

In this meta-analysis, it was determined that low vitamin D levels were associated with the progression of TB. This effect was found to be dose-dependent. This raises the possibility of using vitamin D supplementation in high-risk populations to help decrease TB risk.

 8

Alzheimer’s Dementia

A prospective cohort study of 498 older women was conducted in 2012 to determine the effect of vitamin D on dementia. All subjects received baseline cognitive testing utilizing the Pfeiffer Short Portable Mental State Questionnaire. Only those scoring above 8 (normal cognitive function) were included in the study. 

 

After a seven-year period, the Mini-Mental Status Exam (MMSE) and Grober and Buschke test were conducted to screen for dementia. 

It was determined that the subjects with dementia had a lower average vitamin D intake than those without. (50 vs 59 ug/wk).

 

The subjects in the highest vitamin D intake quintile had a lower incidence of dementia than those in the remaining four quintiles combined (4.1% vs. 17%). 

This study did depend on accurate reporting of vitamin D intake by the subjects tested. About half of the subjects were lost to follow-up during the study period.

 

 9

 

Another small randomized controlled study was conducted in 2015 to determine the effect of vitamin D supplementation on the treatment and prevention of Alzheimer’s disease. Subjects were 60 years of age or older with an MMSE score of less than 24. 

 

Two groups were randomized. The active group had a baseline vitamin D level of 8.2 ug/ml. This group received 4,000 IU vitamin D supplementation daily. The control group had a baseline vitamin D level of 9.3 ug/ml and received no vitamin D supplementation.

 

The MMSE was administered every three months. No difference was found between the two groups after three months, but a significant difference occurred after six months (24 vs. 22). Although the sample size was small, a positive effect of vitamin D supplementation was observed.

 10

If you are interested in reading about Lewy Body Dementia follow this link.

 

Depression

I became interested in vitamin D due to its effects on depression. I see a large number of depressed patients and have noticed many have a sub-therapeutic vitamin D level. 

 

People who are depressed feel unhappy most of the time. They may lose interest in things they have enjoyed in the past. Depression can cause the person may sleep too much or too little. They may have a difficult time concentrating and isolate. Depressed patients may have a change in appetite and may have low self-esteem.

 

Researchers believe vitamin D may increase the amount of serotonin in the brain.

 11

 

Increasing serotonin and other monoamines are the mechanisms of action of many antidepressants available today. 

 

Even though there seems to be a link between vitamin D and depression, conflicting evidence still exists.

 12

 

There have been many studies conducted, but it remains unclear whether vitamin D helps treat depression or whether vitamin D levels are just lower in depressed patients. 

 

A study conducted in the Netherlands in 2014 showed low vitamin D levels were associated with the severity and presence of depression. This study followed 1102 depressed patients aged 18-65 years and 790 patients who were not currently depressed but had been in the past.

 13

 

A study in Finland in 2015 found higher serum concentrations of vitamin D were associated with a lower incidence of depression. The investigators believe higher vitamin D levels protect individuals from becoming depressed.

 14

 

I am a firm believer in utilizing vitamin D supplements for those who are depressed. My recommendation is to take 5000 IU daily. Vitamin D levels can be obtained during your yearly health check-up. 

 

Although I am not depressed, I take vitamin D daily to prevent depression. I live in Oregon and don’t get much sun, especially during the winter months. My vitamin D levels have been low in the past. 

 

Can I Take Too Much Vitamin D?

Yes, because vitamin D is a fat-soluble vitamin, it can accumulate. Hypercalcemia, an increased level of calcium in the blood, is the major consequence of taking too much vitamin D. Hypercalcemia can cause nausea, vomiting, frequent urination and weakness. It may also lead to the formation of kidney stones. A person would need to take a very high dose of vitamin D over a long period to become toxic.

Vitamin D is a critical substance used by our bodies in many ways. I have highlighted many uses of this vital vitamin in this post.

 

I have noticed in my practice that a large percentage of depressed patients have a low vitamin D level.  I believe keeping your level therapeutic is a good step in feeling better and helping your body function as efficiently as possible.

I always recommend vitamin D supplementation in any patient with a level less than 30 ng/ml.  It is an easy preventative measure.

If you have any questions or need further information, please feel free to contact me. As always, I want to thank you for reading my blog. If you have any subjects you would like to learn about; please let me know. 

 

We can all live a happy, healthy, healing life! 

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Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 

Steroid Induced Psychosis

Will taking prednisone make you psychotic?

How about other steroids?

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

What is Psychosis?

Patients with psychosis are not in touch with the real world. They display symptoms of hallucinations and or delusions. They may also speak incoherently or behave in ways that do not fit their current surroundings.

Hallucinations occur when a person senses something that is not there. This can happen with sight, hearing, touch, and smell. 

At times, the patient may experience two or more hallucinations simultaneously. For example, a psychotic patient may kneel to pet a dog that doesn’t exist. They can see the dog and feel the dog as they pet it. They may also hear or smell the non-existent animal.

Delusions happen when a person firmly believes something untrue. They may be convinced they are an influential person or someone famous when, in fact, they are not. Delusional patients may think they are younger than their actual age and in better health. They may also suffer from paranoia and swear that people are out to get them.

These patients may only eat packaged food or stop eating entirely due to fear of being poisoned. Delusions are very hard to treat with medication.

Drugs As A Cause Of Psychosis

When a patient presents with new-onset psychosis, it is vital to obtain a thorough history. If a family member has been diagnosed with a psychiatric disorder, there is an increased chance of the illness spreading to other genetic relatives. We also know a patient often responds to the same medications that were effective for family members. 

One of the first things I look for as a pharmacist is possible drugs that can cause psychosis. There are several potential agents to consider, but I classify them into two broad groups.


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Drugs Of Abuse

These are drugs that are not prescribed by a physician and have a higher incidence of precipitating psychosis. This is true because of the properties of the substance and the erratic dose the patient receives. 

Street drugs are not regulated, so drug content is sporadic. The drugs are usually addictive, and individuals take an increasing dose trying to reach the desired effect. Some examples of these agents are:

Cocaine
Methamphetamine
Marijuana
LSD
PCP
Ecstasy
Ethanol

Prescription Medications

The other group contains medications that are available as prescriptions. It is essential to point out that many of these drugs are also available on the street. Any substance that has the ability to alter mood or perception is a candidate for sale on the black market. Some of these agents are:

Antidepressants
Antipsychotics
Anti-seizure medications
Anticholinergic Drugs (Click to read post on anticholinergics)

Isotretinoin
Dopamine agonists for Parkinsons Disease
Corticosteroids

We will concentrate on corticosteroids for this post.

Types Of Steroids

Anabolic Steroids

These include testosterone as well as synthetic substances that are similar in structure to testosterone and have comparable effects. Testosterone is used to treat specific hormone problems in men. The synthetic molecules are often abused by bodybuilders and athletes to build muscle and boost athletic abilities. These are generally not associated with psychosis. Some examples of this type of steroid are:

Dianabol
Winstrol
Deca-durabolin
Equipoise
Anadrol

Corticosteroids

Corticosteroids are used in modern medicine to remedy a variety of conditions.

They are used in the emergency department to treat asthma attacks, COPD, and croup in children.

They can be used to treat Crohn’s disease, gout, lupus, multiple sclerosis, and other autoimmune disorders. Corticosteroids have an important role in reducing inflammation.

These steroids are also utilized in the treatment of skin conditions such as eczema and rash. They play an essential role in some cancer therapies. Corticosteroids come in a variety of forms including injections, tablets, liquids, creams, ointments, and inhalers. Some examples include:

Prednisone
Prednisolone
Dexamethasone
Betamethasone
Triamcinolone
Methylprednisolone


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Corticosteroid Adverse Effects

Unfortunately, although corticosteroids are useful in many of the conditions described above, they can also cause adverse effects. A few common side effects include:

Weight gain
Agitation
Nausea and vomiting
Insomnia
Headache
Mood swings
Euphoria
Psychosis

Steroid Induced Psychosis

Psychosis is a side effect of corticosteroid use and most commonly occurs at prednisone doses above 20mg/day given over a long period. 1 

2 3 

Roughly ten percent of patients remain psychotic after the steroid dose is decreased. 4 

Patients are usually clear after a two-week course of antipsychotic medications.

Although prednisone is often described as the main corticosteroid involved, other members of the steroid family can also cause psychosis.

Dexamethasone

Dexamethasone is often used in place of prednisone due to its longer duration of action. This glucocorticoid is six times more potent than prednisone.

It is unknown what dose of dexamethasone is most likely to cause psychosis, but it has occurred post-operatively after a single dose.

We should anticipate a psychotic reaction after administering dexamethasone, and for surgery cases, it may be prudent to utilize restraints to prevent self-extubation.

Pre-medicating with haloperidol or olanzapine may prove beneficial in this situation. 5 

Dexamethasone will accumulate in the body more quickly than prednisone due to its longer half-life. For this reason, careful monitoring should occur when giving this agent over a more extended period of time.

Methylprednisolone

An article published in European Psychiatry in March of 2016 describes a case where a thirty-year-old female received three, 80mg daily doses of methylprednisolone following lumbar surgery. This patient had no personal or family history of any psychiatric disorder.

One week after the methylprednisolone was completed, the patient was admitted to the hospital for bizarre delusions, visual and auditory hallucinations, and disorganized thinking.

She was treated with risperidone (up to 6mg/day) and a very short course of diazepam (10mg/day). The patient was discharged several weeks later when the psychosis cleared up. 6 

Treatment

The first thing to attempt when treating corticosteroid-induced psychosis is to stop the offending agent. Unfortunately, this is not always possible. 

There are circumstances when the steroids must be continued. In these cases, our best option is to treat the patient with an antipsychotic medication. 

Which agent we choose is based mostly on the characteristics of the patient. I could write an entire chapter on this subject but will list the agents we utilize most commonly for psychosis on our unit. I will also explain reasons to choose one agent over the other.

Haloperidol

Haloperidol is still widely used due to its familiarity. Physicians like to use what they are most comfortable with. 

Some patients should never receive haloperidol. This medication is contraindicated in Parkinson’s patients. Due to its high dopamine (D2) blocking properties, it makes the movement disorder worse. 

Haloperidol is still very effective and is often used for delirium as well as psychosis. It is available in oral, injectable and long-acting injectable forms

Quetiapine

Quetiapine is the first choice in a patient who has Parkinson’s disease. This drug is also helpful in patients who are having trouble sleeping as it is one of the most sedating antipsychotics available. Quetiapine is only available in oral dosage forms which limits its usefulness in acute situations.

Olanzapine

Olanzapine is one of the most effective medications we have for delirium as well as psychosis. Like haloperidol, it is also available in all dosage forms. 

The main problem with this agent is weight gain. This can be a positive attribute in patients that have a poor appetite, but these days patients tend to be overweight. Olanzapine is usually the medication I initially recommend.

Risperidone

Risperidone is also an effective agent for psychosis, but it is not available in a quick acting injectable form. It can also cause movement disorder side effects, especially at higher doses.

Ziprasidone

Ziprasidone is popular in the emergency department for acute agitation and psychosis due to its availability as a fast-acting injectable. The powder in the vial does take longer to dissolve than olanzapine, and it has cardiac side effects that make it undesirable for elderly patients.

Final Thoughts

There is evidence linking corticosteroid use to psychosis. These medications are used for a variety of ailments. At times, they are needed to treat life-threatening conditions.

Although prednisone is the agent most commonly associated with corticosteroid-induced psychosis, other agents in this class can also lead to psychotic behavior.

It is essential to be aware of the signs of psychosis and seek treatment if you or someone you know is being treated with any of these drugs.

I suggest having someone check on you periodically if you live alone and are taking these medications. Psychotic patients often have no idea they are having a problem until it is discovered by someone else.

If possible, the corticosteroid should be stopped if psychosis develops. If this isn’t prudent, antipsychotic agents can be used based on patient characteristics.

In severe cases, the patient may need to be hospitalized until stable. Most patients will clear after a few days to a couple of weeks.

I hope you have enjoyed this review of corticosteroid-induced psychosis. If you have any questions or comments, please send me an email.

My goal is to make this site as informative and enjoyable as possible for my readers. We can learn the best way to make that happen together.

As always, live a happy, healthy, healing life and remember to HAVE FUN!

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Michael Pharmacist

Michael J. Brown, RPh. BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Read Michael’s story here. Feel free to send Michael a message using this link


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